Within the widening European Union, large-scale movements of people,
animals and food-products increasingly contribute to the potential for
spread of communicable diseases. The EU was given a mandate for public
health action only in 1992, under the Treaty of European Union
("Maastricht Treaty"), which was broadened in the 1997 with the
Treaty of Amsterdam.

While all EU countries have statutory requirements for notifying
communicable diseases, national and regional communicable disease
surveillance practices vary considerably (1). The Network Committee (NC)
for the Epidemiological Surveillance and Control of Communicable Diseases
in the EU was established in 1998 to harmonise these activities (2).

There is wide variation in the public health epidemiology training
available in service and academic institutions in EU countries, and
serious differences in their capacity to respond to communicable disease
threats nationally (3,4). Until recently Europe could not provide a
coordinated response for the investigation and control of major
communicable disease problems occurring internationally. Overall, there is
a critical shortage of similarly trained professionals needed to ensure a
high level of human health protection.

Anticipating these training needs, the European Programme for
Intervention Epidemiology Training (EPIET) started in 1995 as a
collaborative venture of the 15 European member states, plus Norway. In
this article we describe the progress of the EPIET programme and its
achievements to date, and its role in the newly created Network Committee.

EPIET programme

EPIET is a two-year fellowship programme, which
provides training and practical experience in intervention epidemiology at
the national centres for surveillance and control of communicable diseases
in the EU and Norway (hereafter referred to as EU).

The objectives of the programme are:

- to strengthen the surveillance of infectious diseases in EU Member
States and at Community level;

- to develop response capacity at national and at Community level to
meet communicable disease threats through rapid and effective field
investigation and control;

- to develop an European network of public health epidemiologists using
standard methods, and sharing common objectives;

- to contribute to the development of the network for the surveillance
and control of communicable disease at Community level.

EPIET is funded on a project basis by the European Commission and the
EU Member States.

Selection of fellows

EPIET is aimed at EU medical practitioners, microbiologists and
veterinarians who have experience in public health and interest in
infectious disease epidemiology. Ideally, candidates wish to pursue a
career track which will contribute to the network of European public
health epidemiologists after completion of their training.

Eight to ten fellowships are advertised each year. All applications are
received at the EPIET Programme office, sorted by nationality and then
forwarded to a designated institute in the applicants’ country of origin
(table 1). These institutes select and rank up to four candidates among
their national applicants, short-listed candidates select two host
institutes which they would like to join during their fellowship from a
list of EPIET training sites. The potential host sites receive the
applicants' curriculum vitae and, in their turn, rank those who wish to
join them. A panel, comprising the representatives of at least five
participating countries, makes the final selection and determines the
placements of successful candidates. Placements will usually be different
from the fellow's country of origin. Institutes selected to host an EPIET
fellow are those with national responsibilities for communicable disease
surveillance, epidemiology, and public health advice. The training site
selection criteria include an assessment of the centre's potential for the
practice of intervention epidemiology and the quality of training
supervision available for fellows.

Table 1. Institutes participating in EPIET (as of February 2001)

Country

Participating Institute

Austria

Bundesministerium für soziale Sicherheit und Generationen

Belgium

Institut Scientifique de Santé Publique - Louis Pasteur

Denmark

Statens Seruminstitut

Finland

National Public Health Institute

France

Institut de Veille Sanitaire

Germany

Robert Koch-Institut

Greece

National Centre for Surveillance and Intervention

Ireland

National Disease Surveillance Centre

Italy

Istituto Superiore di Sanità

Norway

Statens Institutt for Folkehelse

Portugal

Instituto Nacional de Saúde

Spain

Instituto de Salud Carlos III

Sweden

Swedish Institute for Infectious Disease Control

Netherlands

Rijksinstituut voor Volksgezondheid en Milieu

United Kingdom

Communicable Disease Surveillance Centre Northern Ireland

Scottish Centre for Infection and Environmental Health

PHLS Communicable Disease Surveillance Centre

PHLS Communicable Disease Surveillance Centre Wales

In-service training programme

About 90% of the two-year fellowship is taken up by in-service training
at the host institute. For the fellow to be fully integrated into the host
institute, a good working knowledge of the local language is required and
may be gained at the beginning of the fellowship by intensive language
courses.

Apart from general service duties, each fellow is expected to acquire
practical experience in three areas: (1) Design and/or evaluation of
surveillance systems, (2) investigation of infectious disease outbreaks,
and (3) execution of research projects in the area of public health.
Fellows should also develop communication skills (interaction with media,
scientific presentations, publications in bulletins and scientific
journals) and participate in teaching and training activities.

Training modules

About 10% of the fellowship is taken up by formal training courses.

The EPIET fellowship starts with a three-week introductory course in
infectious disease epidemiology, held every autumn in Veyrier-du-Lac,
France. This course offers systematic lectures in applied epidemiology,
interactive case studies, practical exercises in small groups, and the
development of a study protocol based on a current public health problem
in a EU country.

During the remaining 23 months, four to five one-week courses (modules)
are held in any of the participating institutes in the areas of
communication, immunisation, surveillance, advanced statistics, and rapid
assessment methods in emergencies. Fellows are also encouraged to attend
appropriate courses organised in their host country.

Twice during the two-year training period fellows join alumni and
colleagues from host institutes in an annual EPIET scientific seminar,
where they present papers describing the results of their various services
and research activities.

Training support and supervision

Local supervision in the host institute is a major determinant of the
quality of the training and is provided by a designated trainer who may
spend 10% or more of his/her work time on supervising a fellow. Fellow and
trainer are responsible for ensuring that the EPIET training objectives
and any personal learning objectives related to the fellow’s career are
achieved. Additional support is provided by two to three training
programme coordinators, who are accessible for advice to all fellows.

During the fellowship an EPIET programme coordinator together with a
trainer and an EPIET fellow from different collaborating institutes will
carry out a training site appraisal. For one day they systematically
review the training environment and the training activities of the EPIET
fellow, then make recommendations on how to further enhance training. The
results of the visit are summarised in a formal appraisal report which is
made available to all collaborating institutes and reviewed in the course
of follow-up visits.

Programme outcomes

To date (February 2001), 62 fellows have entered the EPIET programme
(n=51) or the closely affiliated German FETP (n=11) (4). Currently, 43
fellows have completed their training; another 19 are still in training.
Figure 1 shows the number of fellows by their country of origin and their
country of training.

The average age for the 51 EPIET fellows on entry into the programme
was 35 years (range 26-46). Forty-one (80%) were medically qualified, 6
were veterinarians (12%) and one each a biologist, a pharmacist, a social
scientist and a research scientist. Thirty-three (65%) fellows held a
Masters' or higher degree in a public health-related field (MPH, MSc,
PhD); 27 (53%) had worked outside of their own country for variable
lengths of time before joining the programme.

Among the 36 EPIET fellows of the first four cohorts, 33 were
subsequently employed in an environment where they could apply and further
develop their knowledge and skills acquired. Twenty found employment in
national or regional institutes in their country of origin, four in a
centre with responsibility in European or supranational surveillance, and
five in their host site. Another four fellows extended their training to
obtain specialist accreditation.

The presence of an EPIET fellow has stimulated all institutes to
further develop links with other collaborating institutes within the EU
and to improve their capacity to respond to outbreaks within their
national boundaries (4). Trainers involved with EPIET have gained useful
experience of a wide range of training material and techniques, and the
activity fostered binds between senior infectious disease epidemiologists
from different EU countries. This has led increasingly to a unified
approach to communicable disease surveillance, intervention epidemiology,
and public health research.

Fellows were also involved in comparing surveillance data from
different European countries, e.g. on VTEC infection and Haemolytic
Uraemic Syndrome, Q fever, salmonellosis, campylobacteriosis, sporadic
listeriosis, and legionellosis.

At EU level, EPIET fellows and their colleagues contributed to European
networks, such as the European Working Group on Legionnaires’ Disease
(EWGLI) and the International Surveillance Network for Enteric Pathogens
(ENTER-NET).

Fellows investigated many outbreaks of infectious
disease at local and national level, but were also involved in most major
cross-border investigations within the EU. Between 1999 and 2000, a total
of 61 outbreaks of infectious disease were investigated at national level
with EPIET fellows in the role of lead or co-investigators (table 2).

Table 2. Examples of outbreak
investigations at national and EU level in 1999 and 2000, with EPIET
fellows as lead or co-investigators

At national level

Legionellosis outbreak at a commercial
fair in Kapellen, Belgium, 1999

Stenotrophomonas maltophilia
possibly related to the potable water distribution system in an ICU of a
Belgian hospital, 1999

Viral gastroenteritis in a
health-resort, Finland, December 1999

Tularemia in Finland, 1999

Community outbreak of Hepatitis A in
Roubaix, France, May 2000

Salmonella panama in France,
August – September 2000

MRSA in a university
hospital in Germany, March
2000

Gastroenteritis in a nursing home due to
Norwalk-like virus, Brandenburg, Germany, March 1999

Suspected waterborne outbreak of Norwalk
virus gastroenteritis in a hotel resort in Italy, July 2000

Salmonella typhimurium: in coastal
Norway, February 1999

A whirlpool associated outbreak of
Pontiac fever at a hotel in Northern Sweden, April 1999

While EPIET’s main focus is the Community, the programme has
responded with increasing frequency to requests for participation by
non-EU countries and organisations of the United Nations system,
particularly WHO. Examples are outbreak investigation of major
international importance, the development, implementation or evaluation of
surveillance systems, and other public health related activities (table
3).

Table 3. International missions (outside
EU) in 1999 and 2000 with involvement of EPIET fellows

EPIET fellows also participated as facilitators
in recent training courses in Ireland, Finland, Germany, Estonia, Norway,
and Russia, as
well as, through WHO, in India, Thailand, and Ukraine.

Issues for the future

In 1999, five years after its start, an external evaluation of EPIET
was carried out to assess to what extent the programme achieves its stated
objectives. While the overall assessment of the programme has been very
favourable (5), the evaluation team identified some key areas which require
attention: sustained long-term funding, establishment of clear and externally
validated standards across all training sites, accreditation, and the
integration of EPIET in the European Network for the Epidemiological Surveillance
and Control of Communicable Diseases.

Funding

Member states have struggled to fund an increasing proportion of the
training posts. Inevitably, this has lead to more conditional funding
(funding tied to a particular country, either in a sending or hosting
capacity) and sometimes to the exclusion of countries with limited financial
resources. Recently, excellent applicants have been refused whilst first-rate
training posts remain unfilled. Establishing a European network requires
that all countries have equal access to the programme irrespective of
their ability to make additional financial contributions.

Human health protection requires long-term investment. If EPIET is to
maintain momentum in developing an effective European cadre of intervention
epidemiologists it must be upgraded from a project to a sustainable programme.

Validated standards across all training sites

The quality of training that can be provided by host institutes is variable
and EPIET must help build capacity at weaker training institutions. This
is essential for building an efficient EU Network on communicable diseases.
Possible strategies to strengthen such sites include the placement of
alumni, exchange of senior epidemiologists from various EPIET host institutes,
and more frequent and targeted training-the-trainer sessions. Deployment
of additional personnel for institute strengthening would require new
administrative and financial mechanisms.

Accreditation

The concept of intervention epidemiology has been mainly developed through
the Epidemic Intelligence Service (EIS) Programme in the United States
of America (6). The USA implemented training in intervention epidemiology
in 1951 (7). Since then, over 2000 persons have been trained in this programme
and subsequently contributed to the public health in the USA and beyond.

Despite Europe’s heterogeneity in culture, language and organisation
of health care, EPIET has successfully adopted a training approach similar
to EIS. But accreditation is needed to ensure that high calibre candidates
continue to be attracted. They in turn should expect career prospects
at least as attractive as in academic training programmes (8). While a
two-year training programme is too short to lead independently to national
or European accreditation, the fellowship period should be recognised
towards national accreditation in one of the related disciplines. Currently,
only Ireland and UK have relevant accreditation schemes, and here the
EPIET fellowship has been counted towards accreditation in public health
medicine. Similar arrangements are needed in the other member countries
or at EU level.

Network

The aims of the EU Network Committee and of EPIET are highly complementary.
Developing a European-wide surveillance, early warning and rapid reaction
capability requires competent communicable disease epidemiologists with
a common approach to intervention epidemiology and a shared European perspective.
A shared long-term vision between EPIET and the Network Committee needs
to be developed now to ensure that these needs can be fully met.

2 Decision No 2119/98/EC of the European Parliament and the Council of
24 September 1998 setting up a network for the epidemiological surveillance
and control of communicable diseases in the Community. Official Journal
of the European Communities. 3.10.98: L268/1-5

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